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New research from South Australian scientists has shown that vitamin D (also commonly known as the sunshine vitamin) is unlikely to protect individuals from multiple sclerosis, Parkinson's disease, Alzheimer's disease or other brain-related disorders. The findings, released today in the science journal 'Nutritional Neuroscience' reported that researchers had failed to find solid clinical evidence for vitamin D as a protective neurological agent. "Our work counters an emerging belief held in some quarters suggesting that higher levels of vitamin D can impact positively on brain health," says lead author Krystal Iacopetta, PhD candidate at the University of Adelaide. Based on a systematic review of over 70 pre-clinical and clinical studies, Ms Iacopetta investigated the role of vitamin D across a wide range of neurodegenerative diseases. "Past studies had found that patients with a neurodegenerative disease tended to have lower levels of vitamin D compared to healthy members of the population," she says. "This led to the hypothesis that increasing vitamin D levels, either through more UV and sun exposure or by taking vitamin D supplements, could potentially have a positive impact. A widely held community belief is that these supplements could reduce the risk of developing brain-related disorders or limit their progression." "The results of our in-depth review and an analysis of all the scientific literature however, indicates that this is not the case and that there is no convincing evidence supporting vitamin D as a protective agent for the brain," she says. >> Read more   Source: News Medical Net

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For farmers, drought is a major source of stress. Their livelihoods and communities depend on the weather. To better support farmers and their families we need to better understand the impact of drought on them and their communities. Our research, published today in the Medical Journal of Australia, found young farmers who live and work on farms in isolated areas and are in financial hardship are the most likely to experience personal drought-related psychological stress. Read more: The lessons we need to learn to deal with the 'creeping disaster' of drought

What our study found

To examine farmers’ mental health during droughts, we examined data from the Australian Rural Mental Health Study and rainfall conditions in the months before farmers completed the survey. Importantly, the study covered the period of the Millennium Drought, which had devastating environmental, social and economic impacts on much of southeast Australia from 1997 to 2010. The study captured both drought and wet conditions, which enables comparisons between farmers’ mental health under different climate conditions. The study included 664 farmers from inner and outer regional, remote and very remote New South Wales. Farmers were defined as: (i) people who lived on a farm; (ii) people who worked on a farm; and (iii) people who lived and worked on a farm. The gender distribution of the participants was equal and the majority were 55-64 years old. Of the three groups investigated, farmers who both lived and worked on a farm reported more drought-related impacts and concerns. Moderately dry conditions were related to the highest scores for drought-related concerns and general psychological distress. Interestingly, higher levels of drought-related concerns were also reported following mild to moderate wet conditions. This is possibly related to much of the study area receiving very high spring rainfall during 2010 and suggests drought-related mental health impacts persist beyond the end of the drought. Read more: Farmer suicide isn't just a mental health issue
A range of social, demographic and community factors influenced the personal impact of drought for farmers:
  • Isolation plays a large role in the rural context. Farmers in outer regional, remote and very remote NSW experienced higher levels of concern about drought. Remoteness can mean people aren’t able to engage as much in social networks, which are essential for building resilience.
  • Financial hardship is increasing in rural areas but many people don’t seek financial assistance due to stigma and ingrained stoicism. Younger farmers may also be particularly impacted by less financial security than older farmers.
  • Age matters too. Farmers under the age of 35 experienced higher personal drought-related stress.

What can we do about it?

Protracted drought is a rare but recurring element of the Australian climate. Whatever the cause, future drought is inevitable. Read more: Hairdressers in rural Australia end up being counsellors too
Drought impacts are different from “rapid” climate extremes such as bushfires, floods or cyclones. So drought planning and preparedness needs to consider the impacts of drought on mental health and well-being differently to the way in which we prepare for and respond to “rapid” climate extremes. We know “rapid” climate extremes can have devastating impacts through loss of life, injury and other threats to communities. The effects can be acute or long-term. While many people cope and adapt to rapid climate extremes, we know a substantial proportion will go on to develop mental health problems as a result. Much less is known about chronic, slow-onset climate extremes such as protracted drought. The unfamiliarity, unpredictability and longevity of drought have substantial personal and social consequences over time. The mechanisms for such impacts are not as well known as for “rapid” climate extremes. Our findings suggest the disruption to community viability, the financial strain, loss of property and stock, and impact on future personal hopes are likely to play a role. Supporting rural communities, and especially farmers, to cope with droughts can have benefits for their well-being and mental health. Strengthening personal, financial and social support for farmers may help in adapting to droughts when drought-related stress is affecting their mental health. General practitioners are uniquely placed to support farmers experiencing persistent worry that is affecting their day-to-day functioning. But it’s often trusted people who engage with farmers regularly, such as rural financial counsellors and vets, who occupy first responder roles. Insights from our study are useful for informing the practical steps required to improve farmers’ mental health. These include:
  • reducing stigma about mental health problems to overcome barriers to seeking professional help and advice early
  • professional help to be more readily available and easier to access in rural and remote areas (such as e-health programs)
  • professional education for all health services, including general practitioners, so they can look out for and address the effects of drought-related stress – they need a good understanding of the pressures facing farmers and farming communities and the ways they can be more alert to their needs
  • community education and public health campaigns so farmers and rural residents can identify the effects of drought-related stress and take appropriate action
  • education and training for non-medical agricultural support services, such as rural financial counsellors, who need to be able to confidently identify early signs of drought-related stress and provide appropriate support
  • continued funding of Rural Adversity Mental Health Program coordinators who link rural and remote residents to services and provide community education and support
  • better opportunities and encouragement to maintain and develop community connections and social networks
  • reasonably priced and reliable internet access to enable increased use of e-health and relieve isolation
  • The Conversationtransparent and consistent information about the processes farmers need to follow to access grants and loans. Farmers should be able to apply for financial support when it’s needed rather than having to fit in with government budget cycles and deadlines. Efficient processing of grant and loan applications is needed to minimise the period of uncertainty and stress while waiting for the outcome.
Emma Austin, PhD Researcher, University of Newcastle; Anthony Kiem, Associate Professor – Hydroclimatology, University of Newcastle; Brian Kelly, , University of Newcastle; David Perkins, Director, Centre for Rural and Remote Mental Health and Professor of Rural Health Research, University of Newcastle; Jane Rich, Research Associate, University of Newcastle, and Tonelle Handley, Research fellow, University of Newcastle This article was originally published on The Conversation. Read the original article.
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Google has claimed it can predict with 95% accuracy when people will die using new artificial intelligence technology. For predicting patient mortality, Google’s Medical Brain was 95% accurate in the first hospital and 93% accurate in the second. It works by analysing patient’s data, such as their age, ethnicity and gender. This information is then joined up with hospital information, like prior diagnoses, current vital signs, and any lab results, reports The Sun. But according to Bloomberg, what impressed medical experts most “was Google’s ability to sift through data previously out of reach: notes buried in PDFs or scribbled on old charts. The neural net gobbled up all this unruly information then spat out predictions. And it did it far faster and more accurately than existing techniques.” It is not the first time Google has made inroads into the medical industry. Its DeepMind subsidiary, considered by some experts to lead the way in AI research, “courted controversy” in 2013 after it was revealed it had access to 1.6 million medical records of NHS patients at three hospitals, reports The Independent.   >> Read More Source: The Week UK

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There’s no way you’d want to go to work when you’ve got the telltale signs of gastro: nausea, abdominal cramps, vomiting and diarrhoea. But what about when you’re feeling a bit better? When is it safe to be around colleagues, or send your kids to school or daycare? The health department recommends staying home from work or school for a minimum of 24 hours after you last vomited or had diarrhoea. But the question of how long someone is contagious after recovering from gastro is a very different question.   What causes gastro? To better understand how long you can be contagious with gastro, we need to look at the various causes. Viruses are the most common causes of gastro. Rotavirus is the leading cause in infants and young children, whereas norovirus is the leading cause of gastro in adults. There are around 1.8 million cases of norovirus infection in Australia each year. This accounts for almost 40% of the total cases of gastro. Bacterial gastroenteritis is also common and accounts for around 1.6 million cases a year. Of those cases, 1.1 million come from E. coli infections. Other bacteria that commonly cause gastro include salmonella, shigella and campylobacter. These bacteria are often found in raw or undercooked meat, seafood, and unpasteurised milk. Parasites such as giardia lamblia, entamoeba histolytica and cryptosporidium account for around 700,000 cases of gastro per year. Most of the time people recover from parasitic gastroenteritis without incident, but it can cause problems for people with weaker immune systems. Read more: Health Check: I feel a bit sick, should I stay home or go to work?   Identifying the bug Most cases of diarrhoea are mild, and resolve themselves with no need for medical attention. But some warrant further investigation, particularly among returned travellers, people who have had diarrhoea for four or five days (or more than one day with a fever), patients with bloody stools, those who have recently used antibiotics, and patients whose immune systems are compromised. The most common test is the stool culture which is used to identify microbes grown from loose or unformed stools. The bacterial yield of stool cultures is generally low. But if it does come back with a positive result, it can be potentially important for the patient. Some organisms that are isolated in stool cultures are notifiable to public health authorities. This is because of their potential to cause serious harm in vulnerable groups such as the elderly, young children, pregnant women and those with weakened immune systems. The health department must be notified of gastro cases caused by campylobacter, cryptosporidium, listeria, salmonella, shigella and certain types of E.coli infection. This can help pinpoint outbreaks when they arise and allow for appropriate control measures.   You might feel better but your poo isn’t Gastro bugs are spread via the the faecal-oral route, which means faeces needs to come into contact with the mouth for transmission to occur. Sometimes this can happen if contaminated faecal material gets into drinking water, or during food preparation. But more commonly, tiny particles of poo might remain on the hands after going to the toilet. Using toilet paper to wipe when you go to the toilet doesn’t completely prevent the contamination of hands, and even more so when the person has diarrhoea. The particles then make their way to another person’s mouth during food preparation or touching a variety of contaminated surfaces and then putting your fingers in your mouth. After completely recovering from the symptoms of gastro, infectious organisms can still be shed into stools. Faecal shedding of campylobacter, the E. coli O157 strain, salmonella, shigella, cryptosporidium, entamoeba, and giardia can last for many days to weeks. In fact, some people who have recovered from salmonella have shed the bacteria into their stools 102 days later. Parasites can remain alive in the bowel for a long period of time after diarrhoea finishes. Infectious cryptosporidium oocysts can be shed into stools for up to 50 days. Giardia oocysts can take even longer to be excreted.   So, how long should you stay away? Much of the current advice on when people can return to work, school or child care after gastro is based on the most common viral gastroenteritis, norovirus, even though few patients will discover the cause of their bug. For norovirus, the highest rate of viral shedding into stools occurs 24 to 48 hours after all symptoms have stopped. The viral shedding rate then starts to quickly decrease. So people can return to work 48 hours after symptoms have stopped. Yes, viral shedding into stools can occur for longer than 48 hours. But because norovirus infection is so common and recovery is rapid, it’s not considered practical to demand patients’ stools be clear of the virus before returning to work. While 24 hours may be appropriate for many people, a specific 48-hour exclusion rule is considered necessary for those in a higher-risk category for spreading gastro to others. These include food handlers, health care workers and children under the age of five at child care or play group. If you have a positive stool culture for a notifiable organism, that may change the situation. Food handlers, childcare workers and health-care workers affected by verotoxin E.coli, for example, are not permitted to work until symptoms have stopped and two consecutive faecal specimens taken at least 24 hours apart have tested negative for verotoxin E. coli. This may lead to a lengthy exclusion period from work, possibly several days.   How to stop the spread Diligently washing your hands often with soap and water is the most effective way to stop the spread of these gastro bugs to others. Consider this: when 10,000 giardia cysts were placed in the palm of a hand, handwashing with soap eliminated 99% of them. To prevent others from becoming sick, disinfect contaminated surfaces thoroughly immediately after someone vomits or has diarrhoea. While wearing disposable gloves, wash surfaces with hot water and a neutral detergent, then use household bleach containing 0.1% hypochlorite solution as a disinfectant.

Clinical Articles iconClinical Articles

There are new changes to Medicare from November 1, 2018, which will affect how GPs can order sleep studies and how they follow up the results. These changes have been introduced by the MBS Review Taskforce and Government to improve doctor assessment and management of a patient having a sleep study.

What are the new Medicare changes?

From November 1 2018:
  • GPs will need to administer screening questionnaires before directly ordering a Medicare rebatable sleep study.
  • Only if these screening questionnaires are positive, can GPs refer directly for a Medicare rebatable sleep study test.
  • The screening questionnaires restrict testing to patients with a “high probability for symptomatic, moderate to severe obstructive sleep apnoea”.
  • Following sleep study testing, “the results and treatment options following any diagnostic sleep study should be discussed during a professional attendance with a medical practitioner before the initiation of any therapy”.
If the screening questionnaires are not positive, patients will need to be referred to Sleep or Respiratory Physicians for assessment and testing. Diagnostic sleep studies can only be rebated once a year.  

Why were the changes made?

 The MBS Review Taskforce noted a very large growth in sleep study testing, especially home sleep study testing, and were concerned that better access to testing has been associated with less appropriate referrals for testing. The Taskforce noted a lack of Sleep or Respiratory Physician review of patients for advice regarding the diagnosis and treatment of OSA. Related to this was a concern that some models of care were promoting home sleep study testing and then advising patients to proceed to CPAP “at lower apnoea-hypopnoea index (AHI) thresholds than is conventionally recommended as indicative of OSA requiring treatment.” The Taskforce commented that there may be a “commencement on CPAP which in some cases is not clinically indicated and does not address their sleep related problem. In this (later) scenario, patients purchase CPAP devices that may deliver little benefit, often based on advice from non-health professionals, and with no medical consultation involved.”  

What do GPs need to do differently?

For adult sleep disorders, GPs can refer to a Sleep or Respiratory Physician for further testing and management (unchanged). This is particularly relevant and important if the patient has atypical symptoms of OSA; have a BMI > 30 and obesity hypoventilation is suspected; or they have symptoms of non-OSA sleep disorders that require management (e.g. insomnia, parasomnias, restless legs syndrome, primary hypersomnolence, etc.) OR GPs can refer directly for a sleep study to investigate OSA (subject to the new specific rules below) Direct referral for a sleep study by a GP should be for patients who have a high probability for symptomatic, moderate to severe obstructive sleep apnoea using the following screening tools:
  • An Epworth Sleepiness Scale score of 8 or more; AND
  • One of the following
    • A STOP-BANG score of 4 or more; or
    • An OSA-50 score of 5 or more; or
    • A high risk score on the Berlin Questionnaire.
The screening questionnaires must be administered by the referring practitionerUnattended (home) sleep studies are suitable for many patients with suspected OSA but patients with other sleep disorders should undergo an attended (laboratory) study.  If GPs refer direct for sleep study testing, a doctor (GP or Sleep/Respiratory Physician) should see the patient after the test to discuss the results and advise on the best management for the patient’s sleep condition.  

The future for primary care and sleep disorders

GPs and Sleep Specialists need to work closely together to co-manage the range and high prevalence of sleep disorders. The new Medicare rules place a greater emphasis on medical assessment, before and after sleep study testing, and emphasise the important role that doctors need to take in managing these conditions.

Summary:

  1. For a GP to refer directly for a sleep study, the relevant questionnaires need to be attached to the referral for it to be valid.
  2. Sleep or Respiratory Physician referrals do not need the questionnaires to be filled in.
  3. Patients must be seen by a doctor before the study for the questionnaires to be filled, and after the study,before any treatment is initiated.
  4. The number of Medicare rebatable sleep studies per patient per year has been limited.

Screening questionnaires:

See link: http://www.sleepcentres.com.au/tl_files/PDF/referral_form_PDF.pdf See tables attached.  

Epworth Sleepiness Scale

               

OSA-50 Questionnaire

         

STOP-BANG Questionnaire

       

Berlin Questionnaire

Clinical Articles iconClinical Articles

Cutaneous disorders are among the most common conditions presented to primary care doctors. Many are easily identifiable and may be dealt with effectively without the need for cutaneous biopsy. Nevertheless, in many instances the diagnosis is not obvious on clinical grounds. The rash may display atypical features or may not respond to therapy as predicted. In these cases, and when dealing with cutaneous tumours or worrying pigmented lesions, cutaneous biopsy with histological assessment becomes necessary. The art of cutaneous biopsy is to derive the maximum amount of information from the minimum amount of tissue, causing least discomfort to the patient. This will be achieved if due regard is given to the advantages and shortcomings of the various techniques available for biopsying cutaneous tissue, and if the pathologist is supplied with a good clinical history.

Clinical History

For several reasons, clinical history assists greatly in the interpretation of skin biopsies. Clinicopathological correlation is particularly important in many inflammatory cutaneous disorders. As the histological features can be very similar, clinical notes may help us to arrange a list of provisional diagnoses in order of likelihood. The key features to discuss with regard to cutaneous rashes include:
  • duration
  • distribution
  • description (macular, papular, vasculitic or vesicular)
  • drugs or other possible aetiological agents
  • provisional clinical diagnosis.
As there is wide variation in the normal microscopic picture from different sites, the area biopsied should also be stated. For biopsies performed to distinguish between squamous cell carcinoma and keratoacanthoma, the rate of growth of the lesion is important. When sending specimens of pigmented lesions, the degree of clinical suspicion should be stated, together with any history of melanoma within the individual or within the individual’s family. Any condition associated with cutaneous disorders, such as systemic lupus erythematosus, pregnancy or bone marrow transplant, should be mentioned in the clinical notes. The clinical history should also include the type of biopsy procedure used (see below) as this determines the way we handle the specimen in the laboratory. For example, the whole of an incisional biopsy will be blocked in order to gain the maximum amount of information, whereas an excisional biopsy will be transversely sectioned in order to fully assess the lateral excision margins in the case of a tumour biopsy.

Excision Biopsy

This is the best technique to use for pigmented lesions and cutaneous tumours. It allows for histological assessment and diagnosis of the lesion, and assessment of surgical excision margins. If appropriate, an orientation suture can be placed at one end of the excision, e.g. the superior end of the specimen, so that if the excision is inadequate, the margin involved can be indicated on an accompanying diagram. Occasionally, excision biopsy is appropriate for inflammatory cutaneous disorders where the condition is characterised by the formation of vesicles. The best chance of removing an intact vesicle (which greatly aids diagnosis) may be through excision.

Incision Biopsy

With incision biopsy, a thin elliptical biopsy is taken radially through the edge of the tumour or through the edge of a macular or annular rash. Incision biopsy is superior to punch biopsy for diagnosing rashes, more tissue is displayed on histological section and scarring is often reduced. A typical incision biopsy is 5-6 mm in length and about 2 mm in width. It should be deep enough to extend into the subcutaneous adipose tissue. The biopsy should run radially from the centre or central areas of the lesion to include approximately 1 mm of normal cutaneous tissue surrounding the lesion.

Punch Biopsy

Punch biopsies are easier to perform and, in general, are more convenient. Nevertheless, they nearly always yield less information than an incision biopsy. For tumours, the biopsy should be taken centrally. For cutaneous eruptions, the biopsy should be taken from an area typical of the rash. In some cases, multiple biopsies may increase the amount of information. In this procedure, it is best not to include normal skin. Punch biopsies come in various sizes. As 2 mm punches often yield inadequate information for diagnosis, a 3 mm punch biopsy is the smallest that should be used.

Shave Biopsy/Curettage

This technique is suitable for superficially-located lesions with plaque-like clinical features, e.g. seborrhoeic keratoses. It is not an appropriate technique for nodular lesions, cutaneous rashes or melanocytic lesions.

General comments concerning cutaneous biopsies

Preparation of the skin surface: Be gentle when cleaning the skin surface prior to biopsy; try not to disturb any overlying scale as the keratin layers sometimes contain diagnostic information (e.g. this is where dermatophytic fungi may be seen). Let any alcohol preparation dry before collecting specimens for immunofluorescence. Local anaesthesia: Only a small amount of local anaesthetic is required for punch biopsy procedures (0.5 mL maximum). Too much local anaesthetic within the tissues can distort the histological appearances and simulate dermal oedema. Marking the lesion: It is often prudent to mark the target area for biopsy with an ink marker, as some lesions can blanch following introduction of local anaesthetic. The erythema in many lesions is due to vascular dilatation occurring as part of the inflammatory disorder. Local anaesthetic can cause vasoconstriction and diminish the erythema clinically. This may result in a poorly targeted biopsy yielding subdiagnostic histology. Depth of biopsy: It is best to continue into the subcutaneous adipose tissue so that the entire dermis is represented on histological section. This helps greatly with the categorisation of many inflammatory skin disorders and also demonstrates the deep border of any cutaneous tumour. When performing a punch biopsy, the biopsy instrument appears to ‘give’ when it penetrates the dermal connective tissue into subcutaneous adipose tissue. A similar sensation will be noticed when dissecting free an incision biopsy. Care with biopsy tissue: All too often, after biopsy tissue has been retrieved from the patient, crush artefact occurs during its transfer into formalin. Crush artefact greatly distorts the histological appearance and repeat biopsy may become necessary. Rather than grasping the biopsy tissue with non-tooth forceps, it should be transferred to the specimen container using needle tips, a skin hook or fine forceps, delicately grasping one edge of the biopsy. Fixative: Ordinary blue, 10% buffered formalin supplied with the specimen jars is suitable for nearly all cutaneous biopsies, except those submitted for microbiological culture or immunofluorescent examination. Labelling: Please label all specimen containers with the patient’s name and details, which should match those stated on the request slip. Unlabelled specimens can still be processed and interpreted if they arrive with labelled paperwork; however, the medico-legal status of any generated report is doubtful. The report will usually be generated with a ‘specimen received unlabelled’ comment attached.

Conclusion

Diagnosing cutaneous conditions can be challenging. The chances of success are improved when the clinician, is armed with a variety of biopsy techniques for use in the correct clinical setting, and when the pathologist is supplied with an adequate clinical history.   - General Practice Pathology is a regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.
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While the majority of patients infected with COVID-19 will not require treatment, there is new hope for those that do go on to become seriously ill. A few treatments developed for other illnesses are showing promise, says Clinical Microbiologist and Infectious Diseases Physician Dr Bernard Hudson.

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When it comes to protection in your practice, surgical face masks to limit droplet transmission are the standard recommendation, assuming you can get ahold of them – but what about when seeing patients who have or may have COVID-19?

New research from South Australian scientists has shown that vitamin D (also commonly known as the sunshine vitamin) is unlikely to protect individuals from multiple sclerosis, Parkinson's disease, Alzheimer's disease or other brain-related disorders. The findings, released today in the science journal 'Nutritional Neuroscience' reported that researchers had failed to find solid clinical evidence for vitamin D as a protective neurological agent. "Our work counters an emerging belief held in some quarters suggesting that higher levels of vitamin D can impact positively on brain health," says lead author Krystal Iacopetta, PhD candidate at the University of Adelaide. Based on a systematic review of over 70 pre-clinical and clinical studies, Ms Iacopetta investigated the role of vitamin D across a wide range of neurodegenerative diseases. "Past studies had found that patients with a neurodegenerative disease tended to have lower levels of vitamin D compared to healthy members of the population," she says. "This led to the hypothesis that increasing vitamin D levels, either through more UV and sun exposure or by taking vitamin D supplements, could potentially have a positive impact. A widely held community belief is that these supplements could reduce the risk of developing brain-related disorders or limit their progression." "The results of our in-depth review and an analysis of all the scientific literature however, indicates that this is not the case and that there is no convincing evidence supporting vitamin D as a protective agent for the brain," she says. >> Read more   Source: News Medical Net

Clinical Articles iconClinical Articles

For farmers, drought is a major source of stress. Their livelihoods and communities depend on the weather. To better support farmers and their families we need to better understand the impact of drought on them and their communities. Our research, published today in the Medical Journal of Australia, found young farmers who live and work on farms in isolated areas and are in financial hardship are the most likely to experience personal drought-related psychological stress. Read more: The lessons we need to learn to deal with the 'creeping disaster' of drought

What our study found

To examine farmers’ mental health during droughts, we examined data from the Australian Rural Mental Health Study and rainfall conditions in the months before farmers completed the survey. Importantly, the study covered the period of the Millennium Drought, which had devastating environmental, social and economic impacts on much of southeast Australia from 1997 to 2010. The study captured both drought and wet conditions, which enables comparisons between farmers’ mental health under different climate conditions. The study included 664 farmers from inner and outer regional, remote and very remote New South Wales. Farmers were defined as: (i) people who lived on a farm; (ii) people who worked on a farm; and (iii) people who lived and worked on a farm. The gender distribution of the participants was equal and the majority were 55-64 years old. Of the three groups investigated, farmers who both lived and worked on a farm reported more drought-related impacts and concerns. Moderately dry conditions were related to the highest scores for drought-related concerns and general psychological distress. Interestingly, higher levels of drought-related concerns were also reported following mild to moderate wet conditions. This is possibly related to much of the study area receiving very high spring rainfall during 2010 and suggests drought-related mental health impacts persist beyond the end of the drought. Read more: Farmer suicide isn't just a mental health issue
A range of social, demographic and community factors influenced the personal impact of drought for farmers:
  • Isolation plays a large role in the rural context. Farmers in outer regional, remote and very remote NSW experienced higher levels of concern about drought. Remoteness can mean people aren’t able to engage as much in social networks, which are essential for building resilience.
  • Financial hardship is increasing in rural areas but many people don’t seek financial assistance due to stigma and ingrained stoicism. Younger farmers may also be particularly impacted by less financial security than older farmers.
  • Age matters too. Farmers under the age of 35 experienced higher personal drought-related stress.

What can we do about it?

Protracted drought is a rare but recurring element of the Australian climate. Whatever the cause, future drought is inevitable. Read more: Hairdressers in rural Australia end up being counsellors too
Drought impacts are different from “rapid” climate extremes such as bushfires, floods or cyclones. So drought planning and preparedness needs to consider the impacts of drought on mental health and well-being differently to the way in which we prepare for and respond to “rapid” climate extremes. We know “rapid” climate extremes can have devastating impacts through loss of life, injury and other threats to communities. The effects can be acute or long-term. While many people cope and adapt to rapid climate extremes, we know a substantial proportion will go on to develop mental health problems as a result. Much less is known about chronic, slow-onset climate extremes such as protracted drought. The unfamiliarity, unpredictability and longevity of drought have substantial personal and social consequences over time. The mechanisms for such impacts are not as well known as for “rapid” climate extremes. Our findings suggest the disruption to community viability, the financial strain, loss of property and stock, and impact on future personal hopes are likely to play a role. Supporting rural communities, and especially farmers, to cope with droughts can have benefits for their well-being and mental health. Strengthening personal, financial and social support for farmers may help in adapting to droughts when drought-related stress is affecting their mental health. General practitioners are uniquely placed to support farmers experiencing persistent worry that is affecting their day-to-day functioning. But it’s often trusted people who engage with farmers regularly, such as rural financial counsellors and vets, who occupy first responder roles. Insights from our study are useful for informing the practical steps required to improve farmers’ mental health. These include:
  • reducing stigma about mental health problems to overcome barriers to seeking professional help and advice early
  • professional help to be more readily available and easier to access in rural and remote areas (such as e-health programs)
  • professional education for all health services, including general practitioners, so they can look out for and address the effects of drought-related stress – they need a good understanding of the pressures facing farmers and farming communities and the ways they can be more alert to their needs
  • community education and public health campaigns so farmers and rural residents can identify the effects of drought-related stress and take appropriate action
  • education and training for non-medical agricultural support services, such as rural financial counsellors, who need to be able to confidently identify early signs of drought-related stress and provide appropriate support
  • continued funding of Rural Adversity Mental Health Program coordinators who link rural and remote residents to services and provide community education and support
  • better opportunities and encouragement to maintain and develop community connections and social networks
  • reasonably priced and reliable internet access to enable increased use of e-health and relieve isolation
  • The Conversationtransparent and consistent information about the processes farmers need to follow to access grants and loans. Farmers should be able to apply for financial support when it’s needed rather than having to fit in with government budget cycles and deadlines. Efficient processing of grant and loan applications is needed to minimise the period of uncertainty and stress while waiting for the outcome.
Emma Austin, PhD Researcher, University of Newcastle; Anthony Kiem, Associate Professor – Hydroclimatology, University of Newcastle; Brian Kelly, , University of Newcastle; David Perkins, Director, Centre for Rural and Remote Mental Health and Professor of Rural Health Research, University of Newcastle; Jane Rich, Research Associate, University of Newcastle, and Tonelle Handley, Research fellow, University of Newcastle This article was originally published on The Conversation. Read the original article.
Clinical Articles iconClinical Articles

Google has claimed it can predict with 95% accuracy when people will die using new artificial intelligence technology. For predicting patient mortality, Google’s Medical Brain was 95% accurate in the first hospital and 93% accurate in the second. It works by analysing patient’s data, such as their age, ethnicity and gender. This information is then joined up with hospital information, like prior diagnoses, current vital signs, and any lab results, reports The Sun. But according to Bloomberg, what impressed medical experts most “was Google’s ability to sift through data previously out of reach: notes buried in PDFs or scribbled on old charts. The neural net gobbled up all this unruly information then spat out predictions. And it did it far faster and more accurately than existing techniques.” It is not the first time Google has made inroads into the medical industry. Its DeepMind subsidiary, considered by some experts to lead the way in AI research, “courted controversy” in 2013 after it was revealed it had access to 1.6 million medical records of NHS patients at three hospitals, reports The Independent.   >> Read More Source: The Week UK

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There’s no way you’d want to go to work when you’ve got the telltale signs of gastro: nausea, abdominal cramps, vomiting and diarrhoea. But what about when you’re feeling a bit better? When is it safe to be around colleagues, or send your kids to school or daycare? The health department recommends staying home from work or school for a minimum of 24 hours after you last vomited or had diarrhoea. But the question of how long someone is contagious after recovering from gastro is a very different question.   What causes gastro? To better understand how long you can be contagious with gastro, we need to look at the various causes. Viruses are the most common causes of gastro. Rotavirus is the leading cause in infants and young children, whereas norovirus is the leading cause of gastro in adults. There are around 1.8 million cases of norovirus infection in Australia each year. This accounts for almost 40% of the total cases of gastro. Bacterial gastroenteritis is also common and accounts for around 1.6 million cases a year. Of those cases, 1.1 million come from E. coli infections. Other bacteria that commonly cause gastro include salmonella, shigella and campylobacter. These bacteria are often found in raw or undercooked meat, seafood, and unpasteurised milk. Parasites such as giardia lamblia, entamoeba histolytica and cryptosporidium account for around 700,000 cases of gastro per year. Most of the time people recover from parasitic gastroenteritis without incident, but it can cause problems for people with weaker immune systems. Read more: Health Check: I feel a bit sick, should I stay home or go to work?   Identifying the bug Most cases of diarrhoea are mild, and resolve themselves with no need for medical attention. But some warrant further investigation, particularly among returned travellers, people who have had diarrhoea for four or five days (or more than one day with a fever), patients with bloody stools, those who have recently used antibiotics, and patients whose immune systems are compromised. The most common test is the stool culture which is used to identify microbes grown from loose or unformed stools. The bacterial yield of stool cultures is generally low. But if it does come back with a positive result, it can be potentially important for the patient. Some organisms that are isolated in stool cultures are notifiable to public health authorities. This is because of their potential to cause serious harm in vulnerable groups such as the elderly, young children, pregnant women and those with weakened immune systems. The health department must be notified of gastro cases caused by campylobacter, cryptosporidium, listeria, salmonella, shigella and certain types of E.coli infection. This can help pinpoint outbreaks when they arise and allow for appropriate control measures.   You might feel better but your poo isn’t Gastro bugs are spread via the the faecal-oral route, which means faeces needs to come into contact with the mouth for transmission to occur. Sometimes this can happen if contaminated faecal material gets into drinking water, or during food preparation. But more commonly, tiny particles of poo might remain on the hands after going to the toilet. Using toilet paper to wipe when you go to the toilet doesn’t completely prevent the contamination of hands, and even more so when the person has diarrhoea. The particles then make their way to another person’s mouth during food preparation or touching a variety of contaminated surfaces and then putting your fingers in your mouth. After completely recovering from the symptoms of gastro, infectious organisms can still be shed into stools. Faecal shedding of campylobacter, the E. coli O157 strain, salmonella, shigella, cryptosporidium, entamoeba, and giardia can last for many days to weeks. In fact, some people who have recovered from salmonella have shed the bacteria into their stools 102 days later. Parasites can remain alive in the bowel for a long period of time after diarrhoea finishes. Infectious cryptosporidium oocysts can be shed into stools for up to 50 days. Giardia oocysts can take even longer to be excreted.   So, how long should you stay away? Much of the current advice on when people can return to work, school or child care after gastro is based on the most common viral gastroenteritis, norovirus, even though few patients will discover the cause of their bug. For norovirus, the highest rate of viral shedding into stools occurs 24 to 48 hours after all symptoms have stopped. The viral shedding rate then starts to quickly decrease. So people can return to work 48 hours after symptoms have stopped. Yes, viral shedding into stools can occur for longer than 48 hours. But because norovirus infection is so common and recovery is rapid, it’s not considered practical to demand patients’ stools be clear of the virus before returning to work. While 24 hours may be appropriate for many people, a specific 48-hour exclusion rule is considered necessary for those in a higher-risk category for spreading gastro to others. These include food handlers, health care workers and children under the age of five at child care or play group. If you have a positive stool culture for a notifiable organism, that may change the situation. Food handlers, childcare workers and health-care workers affected by verotoxin E.coli, for example, are not permitted to work until symptoms have stopped and two consecutive faecal specimens taken at least 24 hours apart have tested negative for verotoxin E. coli. This may lead to a lengthy exclusion period from work, possibly several days.   How to stop the spread Diligently washing your hands often with soap and water is the most effective way to stop the spread of these gastro bugs to others. Consider this: when 10,000 giardia cysts were placed in the palm of a hand, handwashing with soap eliminated 99% of them. To prevent others from becoming sick, disinfect contaminated surfaces thoroughly immediately after someone vomits or has diarrhoea. While wearing disposable gloves, wash surfaces with hot water and a neutral detergent, then use household bleach containing 0.1% hypochlorite solution as a disinfectant.

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There are new changes to Medicare from November 1, 2018, which will affect how GPs can order sleep studies and how they follow up the results. These changes have been introduced by the MBS Review Taskforce and Government to improve doctor assessment and management of a patient having a sleep study.

What are the new Medicare changes?

From November 1 2018:
  • GPs will need to administer screening questionnaires before directly ordering a Medicare rebatable sleep study.
  • Only if these screening questionnaires are positive, can GPs refer directly for a Medicare rebatable sleep study test.
  • The screening questionnaires restrict testing to patients with a “high probability for symptomatic, moderate to severe obstructive sleep apnoea”.
  • Following sleep study testing, “the results and treatment options following any diagnostic sleep study should be discussed during a professional attendance with a medical practitioner before the initiation of any therapy”.
If the screening questionnaires are not positive, patients will need to be referred to Sleep or Respiratory Physicians for assessment and testing. Diagnostic sleep studies can only be rebated once a year.  

Why were the changes made?

 The MBS Review Taskforce noted a very large growth in sleep study testing, especially home sleep study testing, and were concerned that better access to testing has been associated with less appropriate referrals for testing. The Taskforce noted a lack of Sleep or Respiratory Physician review of patients for advice regarding the diagnosis and treatment of OSA. Related to this was a concern that some models of care were promoting home sleep study testing and then advising patients to proceed to CPAP “at lower apnoea-hypopnoea index (AHI) thresholds than is conventionally recommended as indicative of OSA requiring treatment.” The Taskforce commented that there may be a “commencement on CPAP which in some cases is not clinically indicated and does not address their sleep related problem. In this (later) scenario, patients purchase CPAP devices that may deliver little benefit, often based on advice from non-health professionals, and with no medical consultation involved.”  

What do GPs need to do differently?

For adult sleep disorders, GPs can refer to a Sleep or Respiratory Physician for further testing and management (unchanged). This is particularly relevant and important if the patient has atypical symptoms of OSA; have a BMI > 30 and obesity hypoventilation is suspected; or they have symptoms of non-OSA sleep disorders that require management (e.g. insomnia, parasomnias, restless legs syndrome, primary hypersomnolence, etc.) OR GPs can refer directly for a sleep study to investigate OSA (subject to the new specific rules below) Direct referral for a sleep study by a GP should be for patients who have a high probability for symptomatic, moderate to severe obstructive sleep apnoea using the following screening tools:
  • An Epworth Sleepiness Scale score of 8 or more; AND
  • One of the following
    • A STOP-BANG score of 4 or more; or
    • An OSA-50 score of 5 or more; or
    • A high risk score on the Berlin Questionnaire.
The screening questionnaires must be administered by the referring practitionerUnattended (home) sleep studies are suitable for many patients with suspected OSA but patients with other sleep disorders should undergo an attended (laboratory) study.  If GPs refer direct for sleep study testing, a doctor (GP or Sleep/Respiratory Physician) should see the patient after the test to discuss the results and advise on the best management for the patient’s sleep condition.  

The future for primary care and sleep disorders

GPs and Sleep Specialists need to work closely together to co-manage the range and high prevalence of sleep disorders. The new Medicare rules place a greater emphasis on medical assessment, before and after sleep study testing, and emphasise the important role that doctors need to take in managing these conditions.

Summary:

  1. For a GP to refer directly for a sleep study, the relevant questionnaires need to be attached to the referral for it to be valid.
  2. Sleep or Respiratory Physician referrals do not need the questionnaires to be filled in.
  3. Patients must be seen by a doctor before the study for the questionnaires to be filled, and after the study,before any treatment is initiated.
  4. The number of Medicare rebatable sleep studies per patient per year has been limited.

Screening questionnaires:

See link: http://www.sleepcentres.com.au/tl_files/PDF/referral_form_PDF.pdf See tables attached.  

Epworth Sleepiness Scale

               

OSA-50 Questionnaire

         

STOP-BANG Questionnaire

       

Berlin Questionnaire

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Cutaneous disorders are among the most common conditions presented to primary care doctors. Many are easily identifiable and may be dealt with effectively without the need for cutaneous biopsy. Nevertheless, in many instances the diagnosis is not obvious on clinical grounds. The rash may display atypical features or may not respond to therapy as predicted. In these cases, and when dealing with cutaneous tumours or worrying pigmented lesions, cutaneous biopsy with histological assessment becomes necessary. The art of cutaneous biopsy is to derive the maximum amount of information from the minimum amount of tissue, causing least discomfort to the patient. This will be achieved if due regard is given to the advantages and shortcomings of the various techniques available for biopsying cutaneous tissue, and if the pathologist is supplied with a good clinical history.

Clinical History

For several reasons, clinical history assists greatly in the interpretation of skin biopsies. Clinicopathological correlation is particularly important in many inflammatory cutaneous disorders. As the histological features can be very similar, clinical notes may help us to arrange a list of provisional diagnoses in order of likelihood. The key features to discuss with regard to cutaneous rashes include:
  • duration
  • distribution
  • description (macular, papular, vasculitic or vesicular)
  • drugs or other possible aetiological agents
  • provisional clinical diagnosis.
As there is wide variation in the normal microscopic picture from different sites, the area biopsied should also be stated. For biopsies performed to distinguish between squamous cell carcinoma and keratoacanthoma, the rate of growth of the lesion is important. When sending specimens of pigmented lesions, the degree of clinical suspicion should be stated, together with any history of melanoma within the individual or within the individual’s family. Any condition associated with cutaneous disorders, such as systemic lupus erythematosus, pregnancy or bone marrow transplant, should be mentioned in the clinical notes. The clinical history should also include the type of biopsy procedure used (see below) as this determines the way we handle the specimen in the laboratory. For example, the whole of an incisional biopsy will be blocked in order to gain the maximum amount of information, whereas an excisional biopsy will be transversely sectioned in order to fully assess the lateral excision margins in the case of a tumour biopsy.

Excision Biopsy

This is the best technique to use for pigmented lesions and cutaneous tumours. It allows for histological assessment and diagnosis of the lesion, and assessment of surgical excision margins. If appropriate, an orientation suture can be placed at one end of the excision, e.g. the superior end of the specimen, so that if the excision is inadequate, the margin involved can be indicated on an accompanying diagram. Occasionally, excision biopsy is appropriate for inflammatory cutaneous disorders where the condition is characterised by the formation of vesicles. The best chance of removing an intact vesicle (which greatly aids diagnosis) may be through excision.

Incision Biopsy

With incision biopsy, a thin elliptical biopsy is taken radially through the edge of the tumour or through the edge of a macular or annular rash. Incision biopsy is superior to punch biopsy for diagnosing rashes, more tissue is displayed on histological section and scarring is often reduced. A typical incision biopsy is 5-6 mm in length and about 2 mm in width. It should be deep enough to extend into the subcutaneous adipose tissue. The biopsy should run radially from the centre or central areas of the lesion to include approximately 1 mm of normal cutaneous tissue surrounding the lesion.

Punch Biopsy

Punch biopsies are easier to perform and, in general, are more convenient. Nevertheless, they nearly always yield less information than an incision biopsy. For tumours, the biopsy should be taken centrally. For cutaneous eruptions, the biopsy should be taken from an area typical of the rash. In some cases, multiple biopsies may increase the amount of information. In this procedure, it is best not to include normal skin. Punch biopsies come in various sizes. As 2 mm punches often yield inadequate information for diagnosis, a 3 mm punch biopsy is the smallest that should be used.

Shave Biopsy/Curettage

This technique is suitable for superficially-located lesions with plaque-like clinical features, e.g. seborrhoeic keratoses. It is not an appropriate technique for nodular lesions, cutaneous rashes or melanocytic lesions.

General comments concerning cutaneous biopsies

Preparation of the skin surface: Be gentle when cleaning the skin surface prior to biopsy; try not to disturb any overlying scale as the keratin layers sometimes contain diagnostic information (e.g. this is where dermatophytic fungi may be seen). Let any alcohol preparation dry before collecting specimens for immunofluorescence. Local anaesthesia: Only a small amount of local anaesthetic is required for punch biopsy procedures (0.5 mL maximum). Too much local anaesthetic within the tissues can distort the histological appearances and simulate dermal oedema. Marking the lesion: It is often prudent to mark the target area for biopsy with an ink marker, as some lesions can blanch following introduction of local anaesthetic. The erythema in many lesions is due to vascular dilatation occurring as part of the inflammatory disorder. Local anaesthetic can cause vasoconstriction and diminish the erythema clinically. This may result in a poorly targeted biopsy yielding subdiagnostic histology. Depth of biopsy: It is best to continue into the subcutaneous adipose tissue so that the entire dermis is represented on histological section. This helps greatly with the categorisation of many inflammatory skin disorders and also demonstrates the deep border of any cutaneous tumour. When performing a punch biopsy, the biopsy instrument appears to ‘give’ when it penetrates the dermal connective tissue into subcutaneous adipose tissue. A similar sensation will be noticed when dissecting free an incision biopsy. Care with biopsy tissue: All too often, after biopsy tissue has been retrieved from the patient, crush artefact occurs during its transfer into formalin. Crush artefact greatly distorts the histological appearance and repeat biopsy may become necessary. Rather than grasping the biopsy tissue with non-tooth forceps, it should be transferred to the specimen container using needle tips, a skin hook or fine forceps, delicately grasping one edge of the biopsy. Fixative: Ordinary blue, 10% buffered formalin supplied with the specimen jars is suitable for nearly all cutaneous biopsies, except those submitted for microbiological culture or immunofluorescent examination. Labelling: Please label all specimen containers with the patient’s name and details, which should match those stated on the request slip. Unlabelled specimens can still be processed and interpreted if they arrive with labelled paperwork; however, the medico-legal status of any generated report is doubtful. The report will usually be generated with a ‘specimen received unlabelled’ comment attached.

Conclusion

Diagnosing cutaneous conditions can be challenging. The chances of success are improved when the clinician, is armed with a variety of biopsy techniques for use in the correct clinical setting, and when the pathologist is supplied with an adequate clinical history.   - General Practice Pathology is a regular column each authored by an Australian expert pathologist on a topic of particular relevance and interest to practising GPs. The authors provide this editorial free of charge as part of an educational initiative developed and coordinated by Sonic Pathology.
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While the majority of patients infected with COVID-19 will not require treatment, there is new hope for those that do go on to become seriously ill. A few treatments developed for other illnesses are showing promise, says Clinical Microbiologist and Infectious Diseases Physician Dr Bernard Hudson.

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When it comes to protection in your practice, surgical face masks to limit droplet transmission are the standard recommendation, assuming you can get ahold of them – but what about when seeing patients who have or may have COVID-19?

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